Is the whole-body cryotherapy a beneficial supplement to exercise therapy for patients with ankylosing spondylitis?

Abstract

BACKGROUND:

The treatment of ankylosing spondylitis (AS) patients requires a combination of non-pharmacological (education, exercise and physical therapy), as well as pharmacological treatment modalities. The optimal management of AS still remains unresolved.

OBJECTIVE:

The aim was to measure and compare the effects of whole-body cryotherapy (WBC) at $-$ 110 ${}^{\circ}$ C and at $-$ 60 ${}^{\circ}$ C and exercise therapy alone on disease activity and the functional parameters of patients with AS.

METHODS:

Ninety-two patients were allocated to three groups: with WBC at $-$ 110 ${}^{\circ}$ C or at $-$ 60 ${}^{\circ}$ C (each concurrent with exercise therapy), or exercise therapy alone. Disease activity and the functional parameters of the patients were measured at study entry and at the end of the 8-day treatment.

RESULTS:

Supervised therapy, irrespective of the program, led to a significant reduction in disease activity (Bath Ankylosing Spondylitis Disease Activity Index: BASDAI, Ankylosing Spondylitis Disease Activity Score: ASDAS-CRP), disease-related back pain, fatigue, duration and intensity of morning stiffness and a significant improvement in the patient’s functional capacity (Bath Ankylosing Spondylitis Functional Index: BASFI), spine mobility (Bath Ankylosing Spondylitis Metrology Index: BASMI) and chest expandability, with no changes in the levels of CRP. It has been demonstrated that following therapy, the group that underwent cryotherapy at $-$ 110 ${}^{\circ}$ C manifested significantly reduced disease activity (BASDAI) compared with exercise therapy only ( $p=$ 0.024).

CONCLUSION:

Adding cryotherapy at $-$ 110 ${}^{\circ}$ C to exercise therapy led to significantly reduced disease activity expressed in BASDAI, compared with exercise therapy alone.

Keywords

Ankylosing spondylitis disease activity whole-body cryotherapy exercise therapy rehabilitation

1. Introduction

Ankylosing spondylitis (AS) is a chronic, progressive inflammatory rheumatic disease of unknown etiology. This condition mainly affects the axial skeleton including the sacroiliac joints, spine joints, ligaments, and intervertebral discs and it may also involve the peripheral joints as well as specific organs like the eyes or bowels. AS is characterised clinically by pain, reduced spine mobility, limitations in physical functioning, and often results in disability and poor quality of life [1]. The pathogenesis of the disease is still not clear. The role of genetic, immunological and inflammatory factors in the development of the disease is considered [1].

The treatment of AS patients requires a combination of non-pharmacological (education, exercise and physical therapy) [1], as well as pharmacological treatment modalities [2]. The main goals of physiotherapy are to reduce pain, improve mobility, prevent spinal deformation, and improve overall function [3]. The optimal management of AS still remains unresolved [4].

Dagfinrud et al. [3] state that the opinion of experts concerning non-pharmacological treatment is positive, even though there is little evidence for it. It is considered that exercise therapy – the most frequently used physiotherapy treatment – is an important and effective approach for AS patients [1, 2, 3]. However, other physiotherapy modalities commonly used in clinical practice need to be explored [3, 5].

Local cryotherapy and intensive cooling of the whole-body in specially constructed cryogenic chambers has been used for several decades in the comprehensive treatment of patients with rheumatic diseases [6, 7, 8]. Cryotherapy is used in rheumatic diseases empirically as a symptomatic treatment because of its analgesic, anti-inflammatory, myorelaxing [6] and decreased edema results [9]. These effects, especially the relief of pain, enable the patient to intensify the exercises [10]. Cryotherapy used as an adjunct therapy can lead to a reduction in pharmacotherapy and minimize numerous side effects [6].

The effectiveness of cryotherapy in AS patients still remains unexplained. Only a few studies have studied the effect of whole-body cryotherapy on the results of treatment of AS patients [13, 14, 15, 16].

Thus, the primary objective of this study was to quantify the effect of the therapies: whole-body cryotherapy at $-$ 110 ${}^{\circ}$ C and at $-$ 60 ${}^{\circ}$ C (both concurrent with exercise therapy), and exercise therapy alone on disease activity and the functional parameters of patients with AS. The secondary objective was to compare the results of the investigated parameters between WBC groups at $-$ 110 ${}^{\circ}$ C or at $-$ 60 ${}^{\circ}$ C, and the group with exercise applied separately.

2. Materials and methods

2.1 Participants

The study involved 92 nonsmoking patients with ankylosing spondylitis who were divided by the physician into three groups: WBC at $-$ 110 ${}^{\circ}$ C (concurrent with exercise therapy), WBC at $-$ 60 ${}^{\circ}$ C (concurrent with exercise therapy), and non-WBC group (exercise therapy only).

The enrolment to the study was performed in the group of succeeding patients with a diagnosis of AS according to the modified New York criteria [1].

The study included people aged 18–65 years, who spent 2 weeks in the rheumatology unit. Pharmacotherapy patients, who took non-steroidal anti-inflammatory drugs and corticosteroids with an unchanged dose for 2 weeks before the start and for the duration of the study, were accepted. Furthermore, patients who took DMARDs such as methotrexate and sulfasalazine, were included if their doses had remained unchanged for 12 weeks before and for the duration of the study. The study excluded patients with clinically significant aberrations in kidney and liver function, clinically uncontrolled chronic diseases (particularly, circulatory insufficiency, ischemic heart disease, arterial hypertension, diabetes, chronic obstructive pulmonary disease and bronchial asthma), active infection, cancer either present or in remission, and contraindications for cryotherapy.

All procedures performed in studies involving human participants were in accordance with the ethical standards of the institutional and/or national research committee and with the 1964 Helsinki Declaration and its later amendments or comparable ethical standards.

Informed consent was obtained from all individual participants included in the study.

This study was approved by the Bioethics Committee of the University of Medical Sciences in Poznan (trial number 811/11).

2.2 Whole-body cryotherapy and exercise therapy procedures

The WBC procedures were performed in a cryogenic electric chamber which uses a compressor cooling system to produce an extremely low temperature. Patients wearing minimal clothing (bathing suits), gloves, socks, shoes, a headband covering the ears and a surgical mask on the airway were exposed to cold daily in the following format: 30 seconds in the first room ( $-$ 10 ${}^{\circ}$ C), 30 seconds in the second room ( $-$ 60 ${}^{\circ}$ C), and 3 min in the chamber ( $-$ 110 ${}^{\circ}$ C or $-$ 60 ${}^{\circ}$ C). Before the treatments, patients were informed not to enter the cryo-chamber wearing jewellery, glasses, or contact lenses. The skin and hair had to be dry. During the procedure they walked slowly in a circles without touching another person or the structural elements of the chamber. They had to breathe slowly, taking short breaths through the nose with longer exhalations through the mouth. Immediately after leaving the cryogenic chamber, the patients proceeded to the exercise room.

All groups underwent the same therapy program (individually adjusted, depending on the functional condition of the patient). It consisted of group exercises (general rehabilitation exercises, stretching) and free active exercises to reduce morning stiffness and to mobilise the motor and circulatory systems. The exercises started with a warm-up: 7 minutes of marching on a treadmill [17] and 7 minutes of riding on an exercise bike [18]. The group exercises followed and they were led by a physiotherapist for 30 minutes. They included breathing, isometric and free active exercises (strengthening and improving the range of motion of joints). This was followed by static stretching exercises performed for 15 minutes.

These series of procedures were carried out over an 8-day treatment period, with a break on Saturday and Sunday. The physiotherapist examined the patients twice, one day before the beginning and one day after the treatment, at the same time of the morning, having been given no information about the patients’ groupings. The assessment of AS patients was based on the criteria proposed by the Assessment of SpondyloArthritis International Society (ASAS) [19].

Three patients from the WBC groups discontinued treatment due to respiratory infection and were not included in the study.

2.3 Assessments

2.3.1 Primary outcome measure

The disease activity parameters were assessed using the Bath Ankylosing Spondylitis Disease Activity Index (BASDAI), consisting of 6 questions using a numerical rating scale (0–10) to measure the severity of fatigue, spinal and peripheral joint pain, localised tenderness, and morning stiffness (both qualitative and quantitative) [19]; the Ankylosing Spondylitis Disease Activity Score (ASDAS-CRP) is a composite index with continuous measurement properties, based on patient-reported outcomes (back pain, duration of morning stiffness, patient global assessment, and peripheral joint complaints) and C-reactive protein (CRP) [19]. The intensity of back pain and fatigue, duration and intensity of morning stiffness were measured using a numerical rating scale (0–10).

2.3.2 Secondary outcome measures

The functional parameters were assessed using Bath Ankylosing Spondylitis Functional Index (BASFI) which consists of 8 specific questions regarding function in AS and 2 questions reflecting the patient’s ability to cope with everyday life. Each question was answered on a numerical rating scale (0–10). The mean score of the 10 items then provided the final BASFI index [19]. The Bath Ankylosing Spondylitis Metrology Index (BASMI) assessment included 5 clinical examinations of the spinal column and hip joints – i.e. the distance from the tragus to the wall, lumbar flexion and lateral flexion, cervical rotation, and intermalleolar distance. The ratings were classified on a numerical rating scale (0–10) where 0 was considered as normal mobility. The final BASMI was an average of 5 scores obtained in each test (0–10) [12]. We used chest expansion, defined as the difference in chest circumference at maximal inspiration and expiration at the level of the fourth intercostal space [19].

2.3.3 Analytical procedures

The CRP concentrations in the serum were measured using a specified analyzer Wiener lab. CB 250. The result was expressed in mg/L.

Table 1
Baseline characteristics of the 92 patients with AS

	Group WBC $-$ 110 ${}^{\circ}$ C with	Group WBC $-$ 60 ${}^{\circ}$ C with	Group non-WBC with	$p$
	exercise therapy ( $n=$ 32)	exercise therapy ( $n=$ 31)	exercise therapy ( $n=$ 29)
Age (years)	47.1 (10.17)	49.7 (11.71)	50.3 (10.15)	0.386
Gender M/F	26/6	24/7	20/9
BMI	25.95 (4.35)	27.62 (4.63)	27.60 (5.35)	0.336
Disease duration (years)	12.9 (10.06)	11.5 (11.28)	9.4 (7.73)	0.394
Treatment
NSAID	27	25	21
DMARD synthetic	14	9	5
DMARD biological	1	2

The results are expressed as mean (SD); BMI, body mass index; NSAID, nonsteroidal anti-inflammatory drugs; DMARDs, disease-modifying antirheumatic drugs.

2.3.4 Statistical analysis

The values are expressed as means, standard deviations, medians, and interquartile ranges. The Shapiro-Wilk test was used to check the data for normal distribution. Because some variables in groups and trials were supposed to reject the hypothesis of normal distribution, nonparametric tests were used for further analysis. The Kruskal-Wallis test was used to determine the significance of the differences between three therapies before and after therapy (Tables 1 and 2). To assess the significance of the differences between the first and second examination, the Wilcoxon test was used (Table 2). To determine the significance of the differences between the groups WBC at $-$ 110 ${}^{\circ}$ C and non-WBC, and also between WBC at $-$ 110 ${}^{\circ}$ C and WBC at $-$ 60 ${}^{\circ}$ C, the Mann-Whitney test was used. All the analyses were performed using the Statistical 10.1 package. The level of statistical significance was set at $p<$ 0.05.

3. Results

The baseline characteristics of the subjects by group are shown in Table 1.

The groups did not feature significant baseline differences in terms of age, BMI and disease duration.

The clinical characteristics of the three groups before and after the therapy are presented in Table 2.

Following therapy, in groups WBC at $-$ 110 ${}^{\circ}$ C, WBC at $-$ 60 ${}^{\circ}$ C, and non-WBC respectively, the patients showed significant reductions in BASDAI scores ( $p<$ 0.001), ASDAS-CRP ( $p<$ 0.001), intensity of back pain $p<$ 0.001, intensity of fatigue ( $p<$ 0.001), duration of morning stiffness ( $p=$ 0.002; $p=$ 0.009; $p<$ 0.001), and intensity of morning stiffness ( $p=$ 0.001; $p<$ 0.001; $p<$ 0.001). There were no significant changes in the levels of CRP in all the investigated groups.

After therapy, in groups WBC at $-$ 110 ${}^{\circ}$ C, WBC at $-$ 60 ${}^{\circ}$ C, and non-WBC respectively, the patients showed significant improvements in BASFI scores ( $p<$ 0.001), BASMI scores ( $p<$ 0.001; $p<$ 0.001; $p=$ 0.006), and chest expansion ( $p<$ 0.001; $p<$ 0.001; $p=$ 0.009). After therapy the patients showed significant improvements in mSchober test WBC at $-$ 60 ${}^{\circ}$ C ( $p=$ 0.007), non-WBC ( $p=$ 0.012). After therapy the patients showed significant improvements in tragus to wall distance in groups WBC at $-$ 110 ${}^{\circ}$ C ( $p=$ 0.036) and WBC at $-$ 60 ${}^{\circ}$ C ( $p=$ 0.001).

All the groups were homogenous before the treatment. Following therapy, no significant differences were noted between groups WBC at $-$ 110 ${}^{\circ}$ C and non-WBC with the exception of BASDAI ( $p=$ 0.024). No significant differences were noted after therapy between the WBC groups at $-$ 110 ${}^{\circ}$ C and $-$ 60 ${}^{\circ}$ C.

4. Discussion

The study showed that the 8-day treatment combining whole-body cryotherapy at $-$ 110 ${}^{\circ}$ C and at $-$ 60 ${}^{\circ}$ C both concurrent with exercise therapy, and exercise therapy used separately in patients with AS led to significant improvements in all of the investigated parameters, apart from CRP levels. At the same time, it was noted that the addition of cryotherapy at $-$ 110 ${}^{\circ}$ C to exercise therapy led to significantly lower disease activity after therapy comparing to exercise therapy alone.

In our research, significant differences were noted between the groups treated with WBC at $-$ 110 ${}^{\circ}$ C and exercise used separately, although this was relevant to the effects of the therapy on disease activity expressed in BASDAI but not ASDAS-CRP. In order to assess disease activity, researchers use both BASDAI and ASDAS [20]. However, BASDAI has become the gold standard measure in clinical trials. It has been the preferred instrument for measuring disease activity in AS patients since its development [21].

The results obtained by other authors concerning disease activity after WBC are not dissonant. Some authors indicated a significant reduction of DAS28 in rheumatoid arthritis (RA) patients after WBC [8, 10] and also a lowering of BASDAI in AS patients [10, 14, 15] which corresponds with the current results. On the other hand, Hirvonen et al. [22] indicated that in patients with RA, disease activity (DAS) decreased slightly with no statistically significant differences between the $-$ 110 ${}^{\circ}$ C and $-$ 60 ${}^{\circ}$ C WBC groups.

Table 2
Clinical characteristics of the three groups before and after the therapy

	Group WBC $-$ 110 ${}^{\circ}$ C with			Group WBC $-$ 60 ${}^{\circ}$ C with			Group non-WBC with			p ${}_{\text{B}}$ p ${}_{\text{A}}$
	exercise therapy ( $n=$ 32)			exercise therapy ( $n=$ 31)			exercise therapy ( $n=$ 29)

	Before	After	$p$	Before	After	$p$	Before	After	$p$
BASDAI	5.29 (1.42) (4.9; 4.4–6.6)	3.62 (1.56) (3.25; 2.6–4.1)	$<$ 0.001	5.52 (1.24) (5.9; 4.3–6.4)	3.77 (1.51) (3.2; 2.6–5.1)	$<$ 0.001	5.76 (1.42) (6; 4.6–6.8)	4.32 (1.79) (4.1; 3.7–5.4)	$<$ 0.001	0.5040 0.0924
ASDAS-CRP	3.20 (0.68) (3.15; 2.8–3.6)	2.61 (0.79) (2.58; 2.2–3.1)	$<$ 0.001	3.22 (0.79) (3.22; 2.6–3.8)	2.59 (0.70) (2.59; 2.1–3.1)	$<$ 0.001	3.37 (0.82) (3.38; 3.1–3.9)	2.86 (0.84) (2.85; 2.6–3.4)	$<$ 0.001	0.5030 0.2928
Intensity of back pain (NRS)	5.78 (1.81) (5.75; 4.0–7.0)	3.48 (2.13) (3.25; 1.8–5.5)	$<$ 0.001	5.82 (1.72) (6; 4.5–7.0)	4.07 (3.01) (3; 2.0–5.0)	$<$ 0.001	6.17 (1.55) (6.5; 5.0–7.0)	4.16 (2.13) (4; 2.5–6.0)	$<$ 0.001	0.6245 0.4802
Intensity of fatigue (NRS)	5.97 (2.12) (6; 5–8)	4.25 (2.11) (4; 3–6)	$<$ 0.001	5.84 (1.34) (6; 5–7)	3.68 (1.92) (4; 3–5)	$<$ 0.001	6.52 (1.88) (7; 5–8)	4.72 (2.28) (5; 4–7)	$<$ 0.001	0.2865 0.1357
Duration of ms (NRS)	6.00 (2.82) (5; 3.5–9)	4.47 (3.08) (5; 2–7)	0.002	5.52 (2.74) (5; 3–7)	4.36 (2.11) (4; 3–5)	0.009	5.93 (2.85) (5; 4–9)	4.69 (3.00) (5; 2–7)	$<$ 0.001	0.8129 0.6898
Intensity of ms (NRS)	6.19 (1.75) (6; 5–8)	4.69 (2.63) (4; 3–7)	$<$ 0.001	6.16 (1.77) (7; 5–7)	4.21 (2.32) (3.5; 3– 5)	$<$ 0.001	6.72 (1.89) (7; 6–8)	4.76 (2.25) (5; 3–6)	$<$ 0.001	0.4851 0.7234
CRP (mg/l)	8.59 (11.61) (5.36; 2.9–8.5)	8.28 (10.31) (5.5; 3.5–8.4)	0.973	8.40 (10.27) (4.5; 3.5–8.5)	7.85 (7.76) (5.5; 3.5–8.5)	0.991	9.25 (8.93) (7; 4.0–10.7)	9.32 (9.11) (7; 4.5–9.5)	0.889	0.5384 0.4000
BASFI	5.56 (1.80) (5.75; 4.5–7.1)	4.31 (1.89) (4.4; 2.7–5.5)	$<$ 0.001	5.48 (1.84) (5.8; 4.1–7.1)	4.03 (1.81) (4.1; 2.9–5.1)	$<$ 0.001	5.89 (1.71) (6.1; 4.6–7.3)	4.56 (1.76) (4.4; 3.5–5.9)	$<$ 0.001	0.7712 0.4745
BASMI	5.37 (1.72) (5.67; 4.2–6.2)	4.82 (1.66) (5; 3.2–5.98)	$<$ 0.001	4.96 (1.82) (4.72; 3.7–6.7)	4.48 (1.89) (4.58; 2.7–6.0)	$<$ 0.001	5.27 (1.41) (5.38; 4.3–6.5)	4.92 (1.47) (4.9; 3.8–6.2)	0.006	0.2209 0.6041
Chest expansion (cm)	1.77 (1.10) (1.75; 1.0–2.5)	2.17 (1.11) (1.75; 1.5–3.0)	$<$ 0.001	1.66 (1.20) (1.5; 1.0–2.5)	2.26 (1.27) (2.5; 1.5–3.0)	$<$ 0.001	1.43 (1.29) (1; 0.5–2.5)	1.88 (1.47) (1.5; 0.5–2.5)	0.009	0.4155 0.2268
mSchober test (cm)	2.51 (1.60) (2.5; 1.0–3.5)	2.66 (1.56) (2.5; 1.5–3.5)	0.304	2.35 (1.52) (2.0; 1.0–4.0)	2.98 (1.72) (3.0; 1.5–4.0)	0.007	2.05 (1.55) (2.0; 1.0–3.5)	2.68 (1.80) (2.5; 1.3–3.8)	0.012	0.5621 0.6601
Tragus to wall distance test (cm)	17.8 (7.67) (16.5; 12–23)	17.3 (7.10) (16.0; 11–21)	0.036	17.7 (7.07) (17.0; 12–23)	16.1 (6.78) (16.0; 9.5–22.)	0.001	17.6 (5.18) (17.0; 14–21)	16.8 (5.24) (15.0; 13–20)	0.103	0.9610 0.6157

The results are expressed as mean (SD) (median; interquartile range); BASDAI, Bath Ankylosing Spondylitis Disease Activity Index; ASDAS, Ankylosing Spondylitis Disease Activity Score; BASFI, Bath Ankylosing Spondylitis Functional Index; BASMI, Bath Ankylosing Spondylitis Metrology Index; ms, morning stiffness; NRS, numerical rating scale 0–10; $p<$ 0.05.

The results of our study related to the reduction of disease activity after exercise therapy are in agreement with the results of other authors [23, 24, 25, 26].

At the same time Cagliyan et al. [26] noted that group exercise supervised by a physiotherapist significantly reduced disease activity compared to unsupervised exercise performed by patients at home. In the current study, the exercise therapy was supervised by a physiotherapist.

An analgesic effect was achieved in patients with AS after WBC: one procedure [12], nine procedures [11] and two months after therapy [10]. Cold induced analgesia is related to direct effects such as gate control, decreases of excitability of nociceptors threshold and a slowing of nervous conductivity [9, 27, 28] as well as indirect effects connected with decreased myospasm and edema [9, 29].

The current study demonstrated that the analgesic effect occurs after eight procedures of WBC at temperatures of $-$ 110 ${}^{\circ}$ C and $-$ 60 ${}^{\circ}$ C, which confirms the results obtained among RA patients [8, 22]. However Hirvonen et al. [22] noted a significantly greater reduction in pain perception among RA patients in WBC at $-$ 110 ${}^{\circ}$ C. Perhaps this is due to the fact that the cryotherapy was performed 3 times a day. Guthenbrunner et al. [30] suggested that 3 min cryotherapy at $-$ 65 ${}^{\circ}$ C is sufficient for the reduction of perceived pain in patients with fibromyalgia.

Some authors indicate an analgesic effect in response to exercise therapy [23, 24, 25, 26], which is in line with the results of the current study. Uhrin et al. [31] noted that exercises should be performed daily for 30 minutes, like in our research, to gain health benefits along with reduced pain perception.

The level of fatigue is significant for the assessment of the clinical condition of a patient with AS and is often related to the disease activity [32]. We demonstrated a significant improvement in fatigue in all investigated groups after therapy. Similar to the current study, Cagliyan et al. [26] noted that the level of fatigue was more greatly reduced after group exercises compared to exercises performed at home. However, no research was found on fatigue in AS patients after whole-body cryotherapy.

Cryotherapy leads to a reduction in the level of inflammation parameters. In studies conducted in patients with AS, a reduced level of proinflammatory cytokines after WBC was demonstrated [13, 14, 15]. In the present study, serum concentration of C-reactive protein (CRP) were examined. However, none of the therapies had a significant effect on CRP levels. These observations are consistent with the results obtained in other studies in AS patients [14] and in RA patients [22]. Stanek et al. [16], meanwhile, showed a significant reduction in CRP.

The improvement of functional capacity after whole-body cryotherapy is in line with the observations of Lange et al. [11], who noticed significant progress in functional tests after nine procedures of WBC.

Many authors suggest that applying exercise therapy leads to an improvement in the functional capacity of patients with AS [2, 33, 34, 35] and an increase in spine mobility (BASMI) [24] which is in line with the results of the current study. Moreover, Stanek et al. [16] showed that the WBC group BASFI was significantly higher than the kinesiotherapy group, while in our research there was no significant changes between the groups.

However, no work was found in which the WBC effect was examined by the BASMI index. Calvo-Gutiérrez et al. [36] suggested that BASMI10 should be used as a tool to diagnose and to analyse the sensitivity to change of different treatments and we followed this line of thinking in our research. Our results show that there is no statistically significant difference between the groups after therapy in terms of spine mobility (BASMI).

Our research did not show a significant difference between groups in terms of mSchober and chest expansion, while studies by Stanek et al. [16] showed a significant improvement in these parameters in favour of the group in which WBC was performed. At the same time, both, in the conducted study and the study Stanek et al. [16] the improvement in the mSchober test after the applied treatment was lower than 2.39 cm (Smallest Detectable Difference) [36]. That is why those results might be considered as a measurement error. It should be noted that although this assay is one of the BASMI components, Castro et al. [37], in a systemic review, conclude that measuring spinal mobility in AS may not accurately reflect true spinal mobility.

Tragus-wall distances are related with kyphosis seen in AS and obtained good reliability results [36]. Our studies were not spread between groups. However, taking into account the change after therapy, statistically significant changes were obtained only in groups where WBC ( $-$ 110 ${}^{\circ}$ C and $-$ 60 ${}^{\circ}$ C) were carried out.

It should also be noted that three persons were not included in the study due to respiratory infections during WBC therapy. Hirvonnen et al. [22] observed in the course of cryotherapy (local and whole body) some adverse effects such as respiratory infection, I grade frostbite, headache, worsening of pain and malaise, while another authors observed no complications or side effects related to WBC procedure [15, 38].

Interesting results were obtained from research exploring the effect of WBC in rheological properties of blood [39, 40, 41]. Stanek et al. [39] indicate that WBC leads to improvement of rheological blood properties in AS patients. While the study conducted by Teległow et al. [40] documented an increase in fibrinogen concentration in individuals exposed to WBC, and Kulis et al. [41] observed a significant decrease in the elasticity of erythrocytes after WBC in older women with spondyloarthrosis. These results indicate the need for further research in terms of the safety of conducting WBC, especially in older people.

In conclusion, based on our results, we suggest that an 8-day whole-body cryotherapy (at $-$ 110 ${}^{\circ}$ C and $-$ 60 ${}^{\circ}$ C) or exercise program supervised by a physiotherapist leads to a decrease in disease activity, pain level and an improvement in functional parameters. However, combining an exercise program with WBC at $-$ 110 ${}^{\circ}$ C led to significantly lower disease activity expressed by BASDAI after therapy when compared with exercise therapy alone. This suggests that WBC at $-$ 110 ${}^{\circ}$ C as an addition to exercise can be considered for AS patients.

4.1 Limitations

Our groups were identical in baseline statistics, except for sex and medications. It should be noted that to minimize the potential, negative effect pharmacotherapy on the researched parameters no changes in treatment before start and for the duration of the study were performed. The study consisted of eight procedures. The duration of the therapy was related to a 2 week stay at the rheumatology department. An introductory examination was performed one day before therapy, and a final examination was conducted one day after therapy, both taking place at the same time of the day. The study did not provide any long-term follow-up.

Footnotes

Acknowledgments

The authors would like to thank all participants of this study.

Conflict of interest

None to report.

Abbreviations

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Is the whole-body cryotherapy a beneficial supplement to exercise therapy for patients with ankylosing spondylitis?

Abstract

BACKGROUND:

OBJECTIVE:

METHODS:

RESULTS:

CONCLUSION:

Keywords

1. Introduction

2. Materials and methods

2.1 Participants

2.2 Whole-body cryotherapy and exercise therapy procedures

2.3 Assessments

2.3.1 Primary outcome measure

2.3.2 Secondary outcome measures

2.3.3 Analytical procedures

Table 1 Baseline characteristics of the 92 patients with AS

3. Results

4. Discussion

Table 2 Clinical characteristics of the three groups before and after the therapy

Footnotes

Acknowledgments

Conflict of interest

Abbreviations

References

Table 1
Baseline characteristics of the 92 patients with AS

Table 2
Clinical characteristics of the three groups before and after the therapy